Provider Demographics
NPI:1477183770
Name:THIELEN, PETER MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MICHAEL
Last Name:THIELEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6479 GREENBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-5140
Mailing Address - Country:US
Mailing Address - Phone:734-325-7302
Mailing Address - Fax:
Practice Address - Street 1:7291 N MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2501
Practice Address - Country:US
Practice Address - Phone:734-522-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315132558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist